Provider Demographics
NPI:1366512501
Name:SHORT, KAREN PUTTER (LICSW)
Entity type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:PUTTER
Last Name:SHORT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2846
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-6846
Mailing Address - Country:US
Mailing Address - Phone:978-266-9100
Mailing Address - Fax:978-268-5089
Practice Address - Street 1:254 LITTLETON RD
Practice Address - Street 2:KARENDYTH
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886-3519
Practice Address - Country:US
Practice Address - Phone:978-266-9100
Practice Address - Fax:978-268-5089
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1058821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO4265OtherBCBS PROVIDER ID NUMBER
MAPO4265OtherBCBS PROVIDER ID NUMBER